In order for your practice to participate in NACOR Standard Quality Reporting, a NACOR Participation Agreement
and
an ASA Quality Reporting Agreement are required. If your practice did not previously participate in NACOR Standard Quality Reporting, the required contracts and invoice will be emailed to you once your order is processed.

Order placement includes provider quantities and the NACOR Quality Reporting option for the practice (limited to one option, i.e., select your option: group or individual AND your reporting mechanism: QR or QCDR).

Indicate whether this is a new order, replacing an existing order, or adding providers to an existing order.

Enter provider quantities according to provider type and ASA member status.

Enter contact, practice and billing information.

Click "Submit Order" at the bottom of the form.

You will receive an email confirmation shortly.

Invoice will follow. Terms of payment are net 30 days. No data will be accepted by AQI until payment is received.

Beginning in December 2019, ASA will reconcile purchases against actual data submitted by the practice and generate an additional invoice where applicable. All payments must be received by March 15, 2020. Refunds will not be issued. Example: If a practice ordered NACOR Standard Quality Reporting services for 10 CRNAs but submitted data for 12 CRNAs, ASA will invoice for 2 additional CRNAs. If ASA does not receive payment for the 2 additional CRNAs by March 15, 2020, the additional CRNAs’ data will not be submitted to CMS.

Login information for new participating groups will be emailed to the practice champion (designated in the NACOR Participation Agreement from Step 1 above) once fees are paid.

In order for your practice to participate in NACOR Benchmarking, a NACOR Participation Agreement is required. If your practice did not previously participate in NACOR, the required contracts and invoice will be emailed to you once your order is processed.

Indicate whether this is a new order, replacing an existing order, or adding providers to an existing order.

Enter provider quantities according to provider type and ASA member status.

Enter contact, practice and billing information.

Click "Submit Order" at the bottom of the form.

You will receive an email confirmation shortly.

Invoice will follow. Terms of payment are net 30 days. No data will be accepted by AQI until payment is received.

Beginning in December 2019, ASA will reconcile purchases against actual data submitted by the practice and generate an additional invoice where applicable. All payments must be received by March 15, 2020. Refunds will not be issued. Example: If a practice ordered NACOR BENCHMARKING service for 10 non-ASA member physicians but submitted data for 12 non-ASA member physicians, ASA will invoice for 2 additional physicians.

Login information for new participating groups will be emailed to the practice champion (designated in the NACOR Participation Agreement from Step 1 above) once fees are paid.

A NACOR Participation Agreement is required. If your practice did not previously participate in NACOR, the required contracts, and invoice (if any), will be emailed to you once your order is processed.

Indicate whether this is a new order, replacing an existing order, or adding providers to an existing order.

Enter provider quantities according to provider type and ASA member status.

Enter contact, practice and billing information.

Click "Submit Order" at the bottom of the form.

You will receive an email confirmation shortly.

Invoice will follow. Terms of payment are net 30 days. No data will be accepted by AQI until payment is received.

Beginning in December 2019, ASA will reconcile purchases against actual data submitted by the practice and generate an additional invoice where applicable. All payments must be received by March 15, 2020. Refunds will not be issued. Example: If a practice ordered NACOR BASIC for 10 non-ASA member physicians but submitted data for 12 non-ASA member physicians, ASA will invoice for 2 additional physicians.

Login information for new participating groups will be emailed to the practice champion (designated in the NACOR Participation Agreement from Step 1 above) once fees are paid.

NACOR benefits are included with ASA Member Dues for NACOR Basic only.

Indicate provider quantities for both ASA Current Member and ASA Non-Member participating in reporting for the option selected above.

Provider Quantities (Enter At LEAST one category)

ASA MEMBER Physician Anesthesiologists
*

NON-MEMBER Physician Anesthesiologists
*

ASA MEMBER Care Team Clinicians
*

No Residents

NON-MEMBER Care Team Clinicians
*

No Residents

ASA MEMBER Independent Nurse Anesthetists
*

NON-MEMBER Independent Nurse Anesthetists
*

Total Number of Providers

Total Amount

Calculated Total Amount

Calculated Total Quantity

Name of person placing order
*

First Name Last Name

E-mail address of person placing order
*

Confirmation Email

Contact number of person placing order
*

Practice Name
*

Please provide complete Practice Name

Street Address
*

City
*

State
*

Zip Code
*

Tax Identification Number (TIN)

AQI will need all the Tax ID's for which your organization bills Medicare Part B claims. Most groups use a single Tax ID for this; however if your organization bills separately for your anesthesiologists vs. your CRNA's, or if your organization bills using a different Tax ID for each of the facilities where services are provided, you will need to provide all Tax ID's applicable.

Tax Identification Number (TIN) 1
*

A nine-digit number that the IRS assigns to organizations.

Tax Identification Number (TIN) 2

A nine-digit number that the IRS assigns to organizations.

Tax Identification Number (TIN) 3

A nine-digit number that the IRS assigns to organizations.

Billing Contact Name
*

First Name Last Name

Billing Contact Email
*

Billing Address
*

City
*

State
*

Zip Code
*

{selectThe} Order Preview

{selectReporting}

New, Replace or Append Order: {NewUpdateOrReplaceOrder}

Name: {ContactName} Email: {ContactEmail} Phone: {ContactPhone}

Practice

TIN

{PracticeName}

{taxIdentification1}

{PracticeStreetAddress}

{taxIdentification2}

{PracticeCity}, {PracticeState}, {PracticeZipCode}

{taxIdentification3}

Billing Contact

Email

{BillingContactEmail}

{BillingContactEmail}

{BillingAddress}

{BillingCity}, {BillingState}, {BillingZipCode}

Provider Type

Price

Qty

ASA MEMBER Physician Anesthesiologists

${asa-pa}

{ASAMemPA}

NON-MEMBER Physician Anesthesiologists

${non-pa}

{NonMemPA}

ASA MEMBER Care Team Clinicians
(Exludes Residents)

${asa-ctc}

{ASAMemCTC}

NON-MEMBER Care Team Clinicians
(Exludes Residents)

${non-ctc}

{NonMemCTC}

ASA MEMBER Independent Nurse Anesthetists

${asa-ina}

{ASAMemINA}

NON-MEMBER Independent Nurse Anesthetists

${non-ina}

{NonMemINA}

Total

${TotalAmount}

{TotalProviders}

Please enter your initials to confirm that you are purchasing the above ASA/AQI product.
*